Downloaded from bmj com on December Treatment of postnatal depression by stephan2


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                        Treatment of postnatal depression
                        Victoria Hendrick

                        BMJ 2003;327;1003-1004

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                            This is also good news but presents yet another                   Ortho McNeil, Pharmacia, UCB Pharma, Shire, Solvay, and
                        dilemma. Once a patient has the good fortune of                       Wyeth. He is a principal co-investigator on research studies
                                                                                              sponsored by Abbott Laboratories, AstraZeneca, Bristol-Myers
                        responding to combination treatment and leaving the                   Squibb, Glaxo SmithKline, Elan, Eli Lilly, Merck, National Insti-
                        hospital improved, the questions loom of when and if                  tute of Mental Health, National Institute of Drug Abuse,
                        to taper one agent in the combination and strive for                  Organon, Pfizer, Stanley Medical Research Institute, and UCB
                        monotherapy for maintenance treatment. Only two                       Pharma.
                        randomised controlled studies compare combination
                                                                                              1  Müller-Oerlinghausen B, Berghöfer A, Bauer M. Bipolar disorder. Lancet
                        treatment with maintenance treatment of bipolar                          2002;359:241-7.
                        disorder with monotherapy.11 12 Both found combina-                   2  Keck PE Jr, McElroy SL, Strakowski SM, West SA, Sax KW, Hawkins JM, et
                        tion treatment superior to monotherapy in preventing                     al. Twelve-month outcome of bipolar patients following hospitalization
                                                                                                 for a manic or mixed episode. Am J Psychiatry 1998;155:646-52.
                        relapse, although, not surprisingly, at the cost of a                 3 McElroy SL, Keck PE Jr. Pharmacologic agents for the treatment of acute
                        greater burden of side effects.                                          bipolar mania. Biol Psychiatry 2000;48:615-24.
                                                                                              4 Brambilla P, Barale F, Soares JC. Atypical antipsychotics and mood stabi-
                            The treatment of acute mania cannot really be con-                   lization in bipolar disorder. Psychopharmacology 2003;166:315-32.
                        sidered in isolation from the long term or maintenance                5 Keck PE Jr, Mendlwicz J, Calabrese JR, Fawcett J, Suppes T, Vestergaard
                                                                                                 PA, et al. Pharmacologic treatment of acute mania. J Affect Disord
                        treatment of bipolar disorder, and it is at this interface               2000;59(suppl 1):s31-7.
                        that we lack much needed data. The field is poised for                6 Klein DF. Importance of psychiatric diagnosis in prediction of clinical
                                                                                                 drug effects. Arch Gen Psychiatry 1967;16:118-26.
                        longer term effectiveness studies of combination treat-               7 Grunze H, Kasper S, Goodwin G, Bowden C, Baldwin D, Licht RW, et al.
                        ment, enrolling manic patients who are more broadly                      The World Federation of Societies of Biological Psychiatry (WFSBP)
                                                                                                 guidelines for the biological treatment of bipolar disorders, part II: treat-
                        representative of clinical populations.                                  ment of mania. World J Biol Psychiatry 2003;4:5-13.
                                                                                              8 Licht RW. Limits of the applicability and generalizability of drug trials in
                        Paul E Keck, Jr professor of psychiatry, pharmacology, and               mania. Bipolar Disord 2002;4 (suppl 1):66-8.
                        neuroscience                                                          9 Keck PE Jr, McElroy SL. Outcome in the pharmacologic treatment of
                                                                                                 bipolar disorder. J Clin Psychopharmacol 1996;16(suppl 1):S15-23.
                        Psychopharmacology Research Program, Department of Psychiatry,        10 Zarate CA Jr, Quiroz JA. Combination treatment in bipolar disorder: a
                        University of Cincinnati College of Medicine, 231 Albert Sabin Way,      review of controlled trials. Bipolar Disorders 2003;5:217-25.
                        PO Box 670559, Cincinnati, OH 45267-0559, USA                         11 Solomon DA, Ryan CE, Keitner GI, Miller IW, Shea MT, Kazim A, et al. A
                        (                                                       pilot study of lithium carbonate plus divalproex sodium for the continu-
                                                                                                 ation and maintenance treatment of patients with bipolar I disorder. J
                        Competing interests: PK is a consultant to or a member of the            Clin Psychiatry 1997;58:95-9.
                                                                                              12 Tohen M, Chengappa KNR, Suppes T. Efficacy of olanzapine in
                        scientific advisory boards of Abbott Laboratories, AstraZeneca           combination with valproate or lithium for relapse prevention of bipolar
                        Pharmaceuticals, Bristol Myers Squibb, Corcept, Glaxo Smith-             disorder: an 18-month study. Presented at the American Psychiatric
                        Kline, Janssen Pharmaceutica, Eli Lilly and Company, Novartis,           Association Annual Meeting, 18-23 May 2002, Philadelphia, PA.

                        Treatment of postnatal depression
                        Effective interventions are available, but the condition remains underdiagnosed

News p 1008
                                   ajor depressive episodes after childbirth are              cians.1 The mother’s suffering, coupled with the burden
                                   referred to as postnatal depression or, in the             that her depression places on the family and the
                                   United States, as postpartum depression.                   potential detrimental impact on the relationship
                        During the first six months after delivery the                        between mother and child and the child’s cognitive and
                        prevalence of major depression is estimated at                        social development,w2 call for prompt and effective
                        12-13%.w1 The precise time frame for defining postna-                 methods of screening for postnatal depression. Once
                        tal depression has varied across studies, typically from              identified many, if not most, patients with postnatal
                        one month to one year after childbirth. In an effort to               depression can be treated in primary care settings.
                        standardise the terminology, the Diagnostic and Statisti-                 Surprisingly, only one randomised study has evalu-
                        cal Manual of Mental Disorders, fourth edition, restricted            ated the pharmacological treatment of postnatal
                        the specifier of postpartum onset to depressive                       depression.2 The study entailed a comparison of four
                        episodes occurring within four weeks of delivery. How-                treatment groups (total n = 87): fluoxetine plus a single
                        ever, most studies of postnatal depression have contin-               session of cognitive behaviour therapy; placebo plus a
                        ued to use wider time frames, in part because                         single session of cognitive behaviour therapy; fluoxet-
                        epidemiological studies show that women’s heightened                  ine plus six sessions of cognitive behaviour therapy;
                        vulnerability to depression continues for at least the                and placebo plus six sessions of cognitive behaviour
                        first six months after childbirth. Postnatal depression               therapy. After four weeks of treatment, similar
                        must be distinguished from postnatal blues (“baby                     improvements occurred among women receiving
                        blues”), a common experience following childbirth, in                 either six sessions of cognitive behaviour therapy, or
                        which new mothers experience lability of mood and                     fluoxetine plus one session of cognitive behaviour
                        tearfulness. This mild and self limiting condition                    therapy. The study shows that women’s choice of treat-
                        typically disappears two weeks after delivery.                        ment may be guided by their preference of pharmaco-
                             Unfortunately postnatal depression is often over-                logical or non-pharmacological approaches as both
                        looked in primary care clinics. In a study of 214 women               seem comparably effective.
                        who brought their children to a general paediatric                        Several studies have reported that antidepressants,
Extra references        clinic, 86 reported high levels of depressive symptoms                including sertraline, paroxetine, venlafaxine, and
appear on       on the psychiatric symptom index. Of these women,                     nortriptyline, can be used safely by nursing mothers of
BMJ 2003;327:1003–4     only 29% were identified as depressed by the paediatri-               healthy full term infants.3 4w3 w4 Fluoxetine has been

BMJ VOLUME 327        1 NOVEMBER 2003                                                                                                                     1003
                                        Downloaded from on 11 December 2008

linked with irritability, sleep disturbance, and poor        months of childbirth.12 After one month of treatment,
feeding in some infants exposed to it in breast milk,        mean scores on the Edinburgh postnatal depression
although other reports have not noted adverse                scale among women receiving oestrogen were lower
incidents.5 Although the data regarding antidepres-          than those of women receiving placebo, although the
sants during breast feeding are generally favourable,        scores in both groups remained elevated (more than
little is known about the long term effects of exposure      13), implying that the effect of oestrogen was modest.
to antidepressants on the child’s developing brain.          Its usefulness for postnatal depression is compromised
Many new mothers remain reluctant to take such               further by the problems associated with its use, which
medications while nursing.2                                  include potential endometrial hyperplasia, throm-
     On the other hand several studies have found that       boembolism, and a diminished supply of breast milk.w5
psychotherapeutic interventions for postnatal depres-        No randomised studies have evaluated the usefulness
sion are highly acceptable. One randomised study             of natural progesterone for postnatal depression.
evaluated the use of interpersonal therapy, a time lim-          Small open studies have reported that alternative
ited psychotherapy focusing on interpersonal relation-       approaches, including bright light therapy, massage,
ships and role transitions.6 Ninety nine depressed new       and relaxation training, produce improvements in
mothers were randomised to 12 weeks of interpersonal         postnatal mood. These interventions merit further
therapy or to a waiting list control group. Women            research as they are well tolerated and safe. Also worthy
receiving interpersonal therapy were more likely to          of further research is St John’s wort, currently the most
recover from their depressive episode than women in          widely used herbal supplement in the treatment of
the control group (44% v 14%). In a second study 48          depression. New mothers may mistakenly assume that
new mothers with postnatal depression were ran-              St John’s wort is safe to use during nursing because it is
domised either to five to eight weeks of cognitive           “natural.” Data on its safety during breast feeding are
behaviour therapy at home or to a control group.7            too limited to recommend its use by nursing women.
Recovery rates were higher in the treated group than             Postnatal depression is a highly treatable condition.
the control group.                                           A variety of interventions, including antidepressants
     Additional studies have explored the use of             and psychotherapy, can be helpful. New mothers need
supportive psychotherapy at home for depressed new           not discontinue breast feeding if they initiate certain
mothers. In a randomised trial of 50 women within            antidepressants. A principal challenge remains in more
three months of delivery, counselling by paraprofes-         effectively screening for and identifying this common
sional healthcare workers led to full recovery in 69% of     diagnosis. Also, further studies are needed to compare
the treatment group compared with 38% of the control         treatment approaches and assess preventive and follow
group.8 9 The healthcare workers, who had received a         up interventions.
brief training in non-directive counselling, visited the
                                                             Victoria Hendrick associate professor
mothers at home for half hour sessions over eight
                                                             Unversity of California at Los Angeles, Department of Psychiatry,
weeks. A second randomised study of six weeks of visits
                                                             300 Med Plaza, Suite 2345, Los Angeles, CA 90095, USA
for non-directive counselling by nurses similarly found      (
high rates of recovery in the intervention group (80%)
                                                             Competing interests: VH is on the speakers’ bureau for Glaxo
compared with the control group (25%).10 For harried
                                                             SmithKline, Pfizer, and Forest Pharmaceuticals.
new mothers who may not be able to attend
psychotherapeutic sessions regularly, therapy at home
                                                             1  Heneghan AM, Silver EJ, Bauman LJ, Stein REK. Do pediatricians recog-
has obvious advantages. Its efficacy compared with              nize mothers with depressive symptoms? Pediatrics 2000;106:1367-73.
outpatient psychotherapy and pharmacotherapy                 2 Appleby L, Warner R, Whitton A, Faragher B. A controlled study of
                                                                fluoxetine and cognitive-behavioural counseling in the treatment of post-
requires further study.                                         natal depression. BMJ 1997;314:932-6.
     However, the largest study that compared different      3 Hendrick V, Fukuchi A, Altshuler LL, Widawsky M, Wertheimer A, Brun-
                                                                huber M. Use of sertraline, paroxetine and fluvoxamine by nursing
psychotherapeutic approaches for postnatal depres-              women. Br J Psychiatry 2001;79:163-6.
sion found little benefit at nine months after birth.11 In   4 Wisner KL, Perel JM, Findling RL, Hinnes RL. Nortriptyline and its
                                                                hydroxymetabolites in breastfeeding mothers and newborns. Psychophar-
this study, 93 women with postnatal depression were             macol Bull 1997;33:249-251.
randomised to routine primary care, non-directive            5 Burt VK, Suri R, Altshuler LL, Stowe ZN, Hendrick V, Muntean E. The
                                                                use of psychotropic medications during breast-feeding. Am J Psychiatry
counselling, cognitive behaviour therapy, or psychody-          2001;158:1001-9.
namic therapy.11 Only the psychodynamic therapy pro-         6 O’Hara MW, Stuart S, Gorman LL, Wenzel A. Efficacy of interpersonal
duced a clinically more significant reduction in                psychotherapy for postpartum depression. Arch Gen Psychiatry
depression compared with the control group at 4.5            7 Chabrol H, Teissedre F, Saint-Jean M, Teisseyre N, Roge B, Mullet E. Pre-
months, and by nine months none of the treatments               vention and treatment of post-partum depression: a controlled
                                                                randomized study on women at risk. Psychol Med 2002;32:1039-47.
seemed superior to the control group. The control            8 Holden JM, Sagovsky R, Cox JL.Counselling in a general practice setting:
group may have experienced a higher recovery rate               controlled study of health visitor intervention in treatment of postnatal
                                                                depression. BMJ 1989;298:223-6.
than expected because of the attention they received in      9 Ray KL, Hodnett ED. Caregiver support for postpartum depression.
the recruitment and assessment process. Nevertheless,           Cochrane Database Syst Rev 2001;(3):CD000946.
                                                             10 Wickberg B, Hwang CP. Counselling of postnatal depression: a controlled
the study underscores the importance of further                 study on a population based Swedish sample. J Affect Disord 1996;39:
research comparing alternative treatment approaches             209-16.
                                                             11 Cooper PJ, Murray L, Wilson A, Romaniuk H. Controlled trial of the
for postnatal depression.                                       short- and long-term effect of psychological treatment of post-partum
     The usefulness of transdermal oestrogen for                depression. I. Impact on maternal mood. Br J Psychiatry 2003;182:412-9.
                                                             12 Gregoire AJ, Kumar R, Everitt B, Henderson AF, Studd JW. Transdermal
postnatal depression was evaluated in a study of 61             oestrogen for treatment of severe postnatal depression. Lancet
women with major depression beginning within three              1996;347:930-3.

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